Reimbursement Form

Instructions:

1. Fill out completely with description of reimbursement and breakdown of expenses by budget category (missing info will delay payment).

2. Attach file(s) with copies of all receipts, preferably a PDF.

3. Specify how to deliver payment. A check can be mailed, left in the PTA drawer on campus, or payment can be made via Zelle

4. Leave blank the "approval" and "check" fields at the bottom

Note: A receipt of your submitted request will be automatically emailed to your address in your profile

Reimbursement Information

Total Amount For Reimbursement:

Payment Payable To (Name):

Choose Payment Method

Provide street address for mailed checks, or Zelle phone number or email address (as needed)

Expense 1 - Amount

Expense 1: Account to Be Charged

Expense 1 Is For:

Expense 2 - Amount

Expense 2: Account to Be Charged

Expense 2 Is For:

Expense 3 - Amount

Expense 3: Account to Be Charged

Expense 3 Is For:

Attach Receipt 1

Attach Receipt 2

Attach Receipt 3

Approved By

Approval Date:

(to be completed by the Treasurer)

Date Check Issued

Check Number:

Notes